At-a-glance: The Shipman reports

Dame Janet's final report increased Shipman's death toll

Harold Shipman, the UK's worst serial killer, was jailed in January 2000 for killing 15 of his patients, but it is thought he murdered some 250 in total.

The GP was given 15 life sentences for the murders, committed by administering fatal doses of diamorphine.

However, in January 2004 Shipman was found hanging in his cell in Wakefield Prison.

The Shipman Inquiry, led by Dame Janet Smith, has produced six reports on the doctor's crimes.

Here is a summary of their findings.

Death disguised

The inquiry's first report, released in July 2002, found Shipman had killed 215 patients - confirming him as Britain's worst serial killer.

FIRST REPORT Report in full (2.1MB) Conclusions (150K) Most computers will open PDF documents automatically, but you may need to download Adobe Acrobat Reader Download the reader here

It added that there was a "real suspicion" he had murdered another 45 people and a further 200 deaths were "highly suspicious".

Dame Janet said: "He betrayed their trust in a way and to an extent I believe is unparalleled in history."

She said Shipman had caused "unimaginable distress and grief" and suggested he was addicted to murder.

Shipman 'killed 215'

The Police Investigation of March 1998

The second report was published in July 2003.

SECOND REPORT Report in full (2.6MB)

It found Harold Shipman's three last victims could have been saved if police had carried out an investigation in March 1998 properly.

The report said that the two Greater Manchester Police detectives who investigated the doctor were inexperienced and unfit to handle the case.

As a result they missed many opportunities to bring Shipman's crimes to light.

"If the police and the coroner had moved with reasonable expedition, the lives of Shipman's last three victims would probably have been saved," Dame Janet said.

Shipman inquiry criticises police

Death Certification and the Investigation of Deaths by Coroners

The third report said the system of coroners in England and Wales should be radically reformed with non-suspicious deaths investigated.

THIRD REPORT Report in full (2.7MB)

It said a "complete break with the past" was needed so that the system could detect cases of homicide, medical error and neglect.

The report said that Shipman, through the issuing of death certificates stating natural causes, was able to evade the notice of coroners altogether.

"A way must be found to ensure that all deaths receive a degree of scrutiny and investigation appropriate to their facts and circumstances," Dame Janet said.

Coroners 'need radical reform'

The Regulation of Controlled Drugs in the Community

The fourth report called for measures to prevent doctors stockpiling drugs as Shipman did.

FOURTH REPORT Report in full (1.5MB)

It pointed to instances where both individuals and the systems to monitor the prescription of controlled drugs failed to identify what he was doing and stop him.

It said the Home Office did not restrict Shipman's ability to possess and prescribe controlled drugs after he was convicted of dishonestly obtaining pethedine in 1976 while working as a GP in Todmorden, West Yorkshire.

If Shipman had been investigated he "would probably have ceased killing for a time ... in that way, at least some lives would have been saved," Dame Janet said.

Shipman inquiry drug rules call

Safeguarding Patients: Lessons from the Past - Proposals for the Future

The fifth report said the General Medical Council was doing too little to protect patients and criticised it for "looking after its own".

FIFTH REPORT Report in full (13.7MB) Recommendations (86K)

The document contained over 100 recommendations aimed at a radical shake-up of the watchdog body's structure

Included among them was a suggestion that the GMC's role in both investigating and punishing doctors - its fitness to practise procedures - should be split.

"I believe that, if my recommendations are introduced, the deterrent effect will be considerable, and the chances of a doctor such as Shipman escaping detection will be very much reduced," Dame Janet said.

Shipman report demands GMC reform

Shipman: The Final Report

The inquiry's final report revealed that Shipman had killed up to 15 patients in his early career bringing his total murder toll to an estimated 250 people.

READ THE FINAL REPORT Sixth Shipman report in full (530K)

It found Shipman unlawfully killed three men at Pontefract General Infirmary in the 1970s but that the probable number was "between 10 and 15 patients".

"In many cases I have been unable to reach a definite conclusion," Dame Janet said.

She concluded: "With this sixth report I believe that the inquiry has finally provided as complete a picture of Shipman's activity as it would be possible to give."

Shipman killed 'early in career'